Exploring the barriers and enablers of diabetes care in a remote Australian context: A qualitative study

PLOS ONE RESEARCH ARTICLE Exploring the barriers and enablers of diabetes care in a remote Australian context: A qualitative study Siobhan Bourke☯, Syarifah Liza Munira ID☯, Anne Parkinson ID, Emily Lancsar, Jane Desborough ID* Department of Health Services Research and Policy, National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australia a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 ☯ These authors contributed equally to this work. * Abstract Objective OPEN ACCESS Citation: Bourke S, Munira SL, Parkinson A, Lancsar E, Desborough J (2023) Exploring the barriers and enablers of diabetes care in a remote Australian context: A qualitative study. PLoS ONE 18(7): e0286517. https://doi.org/10.1371/journal. pone.0286517 Editor: Adetayo Olorunlana, Caleb University, NIGERIA Received: November 29, 2022 This qualitative study explored the current barriers and enablers of diabetes care in the Indian Ocean Territories (IOT). Methods A constructivist grounded theory approach that incorporated semi-structured telephone interviews was employed. Initial analysis of the interview transcripts used a line-by-line approach, to identify recurring themes, connections, and patterns, before they were relabelled and categorised. This was followed by axial coding, categorisation refinement, and mapping of diabetes triggers in the IOT. Accepted: May 17, 2023 Published: July 27, 2023 Copyright: © 2023 Bourke et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: Data cannot be shared publicly because they contain potentially sensitive and identifying information as the IOT is a small community with few healthcare professionals providing diabetes care. The participants of this study did not give written or oral consent for their data to be shared publicly and the participant information sheet stated that only researchers associated with the study would have access to interview recordings and full transcripts. Due to the sensitive nature of the research supporting data is not available, however, de-identified excerpts are Participants and setting The IOT, consisting of Christmas Island and the Cocos (Keeling) Islands, are some of the most remote areas in Australia. When compared with mainland Australia, the prevalence of type 2 diabetes in the IOT is disproportionately higher. There were no known cases of type 1 diabetes at the time of the study. Like other remote communities, these communities experience difficulties in accessing health services to prevent and manage diabetes. Twenty health care professionals and health service administrators in the IOT took part in semistructured telephone interviews held during April-June 2020. Participants included GPs, nurses, dietitians, social and community services workers, school principals, and administrators. The interview questions focused on their perceptions of the current diabetes care in place in the IOT and their views on the challenges of providing diabetes care in the IOT. Results We identified four main barriers and two main enabling factors to the provision of effective diabetes care in the IOT. The barriers were: (i) societal influences; (ii) family; (iii) changing availability of food; (v) sustainability and communication. The two main enablers were: (i) PLOS ONE | https://doi.org/10.1371/journal.pone.0286517 July 27, 2023 1 / 18 PLOS ONE Exploring the barriers and enablers of diabetes care in a remote Australian context available within the text of the paper. Researchers wishing to access these data will need to contact the ANU Human Research Ethics Committee at and cite HREC protocol number 2019/687. tailoring interventions to meet local and cultural needs and values; and (ii) proactive compliance with the medical model of care. Funding: This research is funded by the Public Policy and Societal Impact Hub at ANU under the Greenhouse program. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Due to the cultural and linguistic diversity within the IOT, many of the identified barriers and enablers are unique to this community and need to be considered and incorporated into routine diabetes care to ensure successful and effective delivery of services in a remote context. Conclusion Competing interests: The authors have declared that no competing interests exist. Introduction Diabetes represents a major challenge to the Australian health system [1]. Type 1 diabetes (T1D) is less common than type 2 diabetes (T2D), which accounts for nearly 90% of cases globally and is recognised as one of the fastest growing chronic diseases worldwide [2, 3]. Individuals with T2D experience poor health outcomes, including increased risk of cardiovascular disease, kidney failure and diabetes-related eye problems. The management of T2D is complex as it requires significant long-term lifestyle changes, including improved diet, increased physical activity, better medication adherence, and self-management. These lifestyle changes can be difficult to maintain and can be further complicated by social and economic factors, especially in rural and remote geographical areas, creating barriers to effective diabetes management. For example, in rural and remote areas, there is often poor and unreliable access to fresh foods and appropriate health services, resulting in detrimental health outcomes [4–6]. This is a point of concern in Australia, where the prevalence of T2D is significantly higher in rural and remote areas than in metropolitan areas [1]. This study explores the barriers and enablers of diabetes care in a remote Australian context—the Indian Ocean Territories (IOT), which are located 2700 kilometres (km) from Perth, Australia. As there were no known cases of type 1 diabetes in the IOT at the time of the study the focus is on type 2 diabetes care although the findings have relevance for both T1D and T2D care. Gestational diabetes was not within the scope of this study. The IOT comprises two small isolated remote communities in Australia: Christmas Island and the Cocos (Keeling) Islands, which are about 900 km apart. Of the 27 Cocos (Keeling) Islands, only two small coral atolls are inhabited (Home Island and West Island) [7]. Population estimates suggest approximately 3000 people live on Christmas Island and about 545 people live on the Cocos (Keeling) Islands [8]. The IOT have some of the most culturally and linguistically diverse communities in Australia. On Christmas Island, more than half (50.9%) of households speak a non-English language [9], and on the Cocos (Keeling) Islands, it is nearly two-thirds (63.6%) of households [10]. Being external territories, the IOT islands are administered (...truncated)